In our weekly feature section, Pelvic Rehab Report is proud to present this interview with Herman & Wallace instructor Michelle Lyons, PT, MISCP

How did you get started in pelvic rehab?

Like a lot of therapists whom I talk to when I travel and teach, it was after the birth of my daughter, when I realized what an under-served population postpartum women are! After childbirth, the focus almost entirely shifts to the baby, and poor old Mum is left, by and large, to fend for herself. Now, more than ever, when we are looking at shorter hospital stays and the lack of maternity leave, we as pelvic therapists need to grow awareness of the needs of women throughout the life cycle and what we have to offer. Pelvic rehab is a high touch, low risk, cost effective and highly effective (yet under used) treatment option. I am passionate about spreading the Pelvic Rehab Gospel!

Who or what inspired you?

Holly Herman. The woman is a pelvic legend. If you get the chance to take one of her course, do it. An amazing breadth, width and depth of expertise and experience.

What do you find more rewarding about teaching?

Confession: I am a pelvic nerd. I just love talking about the fascinating interplay of anatomy, physiology, psychology, form and function. I am (almost) never happier than when I get to spend a weekend with a group of therapists exploring diagnoses, assessments, interventions and outcomes with a like minded group of pelvic health professionals. Whenever I teach, I always learn something too – I really like the classes I teach to be conversational and we tend to have some interesting sidebars and tangents! But I think that just adds to the learning experience – we have all had different pathways educationally, personally and professionally, and I think that looking at different perspectives and approaches can only be a good thing, especially for the patients we treat.

How did you get started teaching pelvic rehab?

My background was in sports medicine and MSK dysfunction. I come into the wonderful world of pelvic health about 15 years ago. Now I look on that background as being incredibly important – I think in order to be a great pelvic therapist, you really need a solid orthopedic expertise. You can’t treat the pelvic floor without looking at the pelvic girdle (and spine and hips and feet and …..!)

What trends/changes are you finding in the field of pelvic rehab?

I think we are learning more and more about Pain Science – sometimes on a daily basis. I think one of our primary role as pelvic therapists can be as educator – I often say to classes that most people know more about their phones than they do about their own bodies! So having anatomical models, books and learning aids can be a great way to empower our patients. I always emphasize including biopsychosocial approaches in working with patients, talking about issues like central sensitisation, the effects of chronic pain and worry on the brain etc BUT I do think we have to be careful, too, that we don’t ignore the biomedical. Sometimes I worry that the pendulum is swinging too far – we have to be sure that we are addressing the physical problems as well!

The other big trend I see is engagement on social media! Just over a year ago, after I taught a course in the UK, I set up a Facebook group with my friend & colleague, Gerard Greene, called Women’s Health Physiotherapy. We now have over 2300 members from all over the world and it is so heartening to see international colleagues from the US, the UK, Australia, the Middle East and Ireland talking, sharing ideas, questions, resources and clinical reasoning. So reassuring to know that others have dealt with the same problems we may be facing in our daily patient caseloads! The Facebook group has been a great success and in fact we submitted a poster based on the group looking at how SoMe can benefit physiotherapists internationally and it has been accepted for presentation at WCPT in Singapore in May.

If you could get a message to all therapists about pelvic rehab, what would it be?

You have such an amazing skillset – you have the power to effect HUGE change in your patients’ lives. The CSP (the governing body for Physiotherapists in the UK) acknowledges that pelvic health is one of the few growth areas within our profession. I think as pelvic therapists, we have the ability to integrate gynaecological, obstetric, orthopaedic, hormonal, oncological and biopsychosocial systems. We are skilled interviewers, skilled manual therapists and skilled exercise/lifestyle precribers. We have the ability to take our patients from being passive recipients to active participants in their own healthcare. It is the best job in the world!

If you could make a significant change to the field of pelvic rehab or the field of PT, what would it be?

I would love to see our role more widely understood and acknowledged. Most of our medical colleagues don’t know what we do! The other big change I would love to see in the U.S. is national registration – I hear from so many therapists how restrictive individual state licensure is and how it can hold them back from job opportunities. I do understand that this is an issue that is hopefully on the horizon, and I think that will be a huge boost to our profession!

What have you learned over the years that has been most valuable to you? Never stop learning! There are always more books to buy, articles to read and courses to attend, but it is just as important to take time to assimilate new knowledge and always ask yourself – ‘Does this change how I would practise? How? Why?' Got to love that clinical reasoning skill set!!

What is your favorite topic about which you teach?

So….this is a tricky one! I teach the Pelvic Floor series and the Pregnancy series. I have developed a number of specialty topics for Herman & Wallace over the years – The Athlete & the Pelvic Floor, Menopause – a rehab approach, Special Topics – Endometriosis, Infertility & Hysterectomy and Oncology & the Male Pelvic Floor and Oncology & the Female Pelvic Floor. To pick just one is impossible! I truly love teaching them all, but if I had to narrow it down I would have to have joint winners. PF1 because I really see this course as the ‘gateway drug’ to a career in pelvic health – I just love to watch as participants move from that first scary lab session (!) to the end of Day 3 and feeling of ‘Yes! I get this! I love pelvic rehab!’. The other joint winner would have to be Oncology & the Female Pelvic Floor – we have so much to offer the survivors of gynaecological cancers. However, unlike our well publicized and relatively well researched role in prostate cancer rehab, gynae cancer survivors are often left to deal with problems encompassing orthopedic, soft tissue, lymphatic, sexual and continence function issues. We have work to do in raising our profile in cancer survivor-ship programs for these women. So, talking about the effects of cancer and cancer treatment on life with and after cancer is an issue I feel very strongly about.

In order to refer patients to needed care, it is vital that health care providers understand the roles that each provider plays. Within pelvic rehabilitation, this issue presents barriers and opportunities, as many providers do not know about pelvic rehabilitation, and about the wide scope of care that we can provide towards bowel, bladder, sexual dysfunction, and pelvic pain in men, women, and children. An article written by a physiotherapist and published in the British Journal of Midwifery highlights the issues such barriers can cause. Utilizing a focus group of seven 3rd year midwifery students, a researchers asked questions about student midwives' perceptions of the physiotherapist's role in obstetrics. Five distinct themes were proposed as a result of the focus group interviews:

1. Role recognition: in order to enable services for patients, understanding other professional roles is valuable.
2. Lack of knowledge: participants expressed a lack of knowledge about the physiotherapy role, and the students wondered if they should be seeking out that knowledge, or if the physiotherapists should be educating the midwives about their role. Prior inter professional education opportunities, which provides the students with potential for understanding other professions, were not viewed as positive by the students.
3. Perceived views existed: Although participants did not have a clear view of what a physiotherapist's role is in obstetrics, they had developed ideas (accurate or not) about the role.
4. Utilization of physiotherapy: Numerous barriers to utilization of physiotherapy in obstetrics rehabilitation were identified, and variations in referrals and utilization of PT were noted.
5. Benefits of physiotherapy: Participants' lack of knowledge, lack of feedback from patients, and issues such as waiting periods prior to getting care limited the stated benefits of physiotherapy care in obstetrics.

In order to avoid working independently of each other, physical therapists and midwives, along with other care providers for women, must understand the complementary roles we play. One of the best ways that we can create a shared understanding is through spending time in each other's educational or clinical environments. Each of us can take responsibility for providing some level of education towards teaching other providers what we do, what we know, and how we can collaborate. One of the ways that the Institute attempts to make this task easier is to provide you with presentations that are already created for this purpose. Our "What is Pelvic Rehab?" powerpoint presentation allows you to edit the slides created for referring providers. Within the presentation, basic information about pelvic therapy and specific research about pelvic rehabilitation for various conditions is combined. To check out the "What is Pelvic Rehab?" presentation and other patient and provider education materials, head to the Products and Resources page and see what information may help you (and your patients) share information about the role of the pelvic rehabilitation provider in collaboration with other health professionals.

Researchers using a community-based sample in the upper Midwest cities of Minneapolis/St. Paul surveyed 138 women between the ages of 18-49 with diagnosed vulvodynia. Vulvodynia was classified as primary (pain started with first tampon use or sexual penetration) or secondary pain started following a period of intercourse that was not painful. The authors aimed to determine the rates of remission of vulvar pain versus pain-free time periods. Remission was defined in this study as having at least one period of time that was pain-free for at least 3 months. Generalized vulvodynia categorization was made after clinical exam and was determined by the subject having pain at each point on the perineal “clock” with cotton swab provocation.

The authors reported that women diagnosed with primary vulvodynia were 43% less likely to report vulvar pain remission that women with a diagnosis of secondary vulvodynia. They also found that obesity and having generalized versus localized vestibulodynia was associated with reduced rates of remission. The theory was discussed that women who have different types of vulvodynia may have varied underlying mechanisms of pain that lead to differences in symptoms. Specifically, the paper reports on recent brain imaging work that suggests women who have primary vulvodynia demonstrate more characteristics of central pain processing.

In relation to health behaviors (such as seeking pain therapy), the authors state that the data may not be sufficiently powered to determine the influence of therapy on remission. They do agree that “…understanding of both spontaneous remission and improvement owing to therapy will ultimately provide guidance in developing more effective interventions.” Because a significant portion of women do not seek care for vulvar pain (for unknown reasons), a bias is created in the research through the lack of representation of those women who are not being studied through healthcare access.

The research concludes with a few familiar themes including the need for more research studying the clinical courses of primary versus secondary vulvodynia. We are also left with questions about which women seek care and why, how their clinical outcomes and remission history may differ based on intervention and other intrinsic variables such as body mass index, and how central pain processing affects pain duration and remission. If you are interested in learning more about vulvodynia, come to one of our newer courses offered by faculty member Dee Hartmann, Assessing and Treating Women with Vulvodynia. Two entire days are spent discussing vulvodynia theory and clinical skills for helping women optimize their health and function. You still have a few weeks to sign up for this course that takes place next in April in Minneapolis!

In our weekly feature section, Pelvic Rehab Report is proud to present this interview with Herman & Wallace instructor Jennafer Vande Vegte, MSPT, BCB-PMD, PRPC

How did you get started in pelvic rehab?

A supervisor of mine suggested that I go to a course and develop a pelvic floor program. I thought she was nuts. As a late twenty-something, I wanted to work with athletes. Finally she convinced me to go. Imagine my surprise when I felt like a duck in the water in the Pelvic Floor Level 1 class.

Who or what inspired you?

Truly I was smitten by Holly Herman at PF1. Her unique teaching style combining her incredible knowledge and fascinating stories with compassion and clarity is something to behold. Later I met Kathe at PF2A and was so inspired by both of these amazing women.

What have you found most rewarding in treating this patient population?

It is such an honor and a privilege to do what we do. At times we share a facet of our patients lives that even their spouses or best friends don't know about. It is not rare for someone to tell me, "I've never told anyone that before." Being trusted to share in these private experiences with others is a blessing to me.

What do you find more rewarding about teaching?

That's easy! I love the "ah-ha" moment when the light comes on in someone's eyes. When they "get it", whether it's finding the ATLA for the first time or understand another treatment direction for a complex patient, this is the moment that I love. I also treasure being around other people who love to do what I love to do!

How did you get started teaching pelvic rehab?

My hospital hosted the PF series years ago and I got to TA. I invited Holly and Kathe out to dinner and basically begged them to think of me if they ever had a teaching position open. Luckily the company was growing and I was shocked to have an opportunity to teach PF2B within a year. I was thinking maybe in 5 years, but I jumped at the chance.

What was it like the first time you taught a course to a group of therapists?

I was SO nervous. I studied like crazy for 6 months! I thought I did a horrible job until I read the reviews at the end of the course and realized I did okay.

What trends/changes are you finding in the field of pelvic rehab?

The amount of knowledge and research in our field is exploding. There are amazing blogs and recourses online for both patients and therapists to get information. Patients are coming in much more educated. Doctors seem to be getting the message that pelvic floor PT is a good first line option for their patients.

If you could get a message to all therapists about pelvic rehab, what would it be?

Every therapist should know a pelvic floor therapist and know when a consult would be appropriate. All therapists should try to feel more comfortable asking appropriate patients about elimination and sex.

If you could make a significant change to the field of pelvic rehab or the field of PT, what would it be?

I would love to see more of a team approach between physicians, PTs, therapists, pain clinics, nutritionalist, etc. especially in treating complex pelvic pain.

What have you learned over the years that has been most valuable to you?

Oh so much. Listen to your patient and hear what he or she or he is telling you. Don't feel like you have to have everything figured out on the initial evaluation. Treat what you find and continue to evaluate and listen.

What is your favorite topic about which you teach?

I think it changes each time, but right now I am really interested in relaxation techniques and down training especially as we understand more about the brain's involvement in pain responses.

A report in The Canadian Journal of Human Sexuality describes the level of emphasis placed on particular sexual health topics in Canadian medical schools. Both the level of emphasis and the utilized teaching methods among 51 residency programs for obstetrics and gynecology (OBG), family medicine (FM), and undergraduate medicine (UGM) were evaluated. Program Directors and Associate Deans of the respective programs were electronically surveyed about the following topics: contraception, disease prevention, sexual violence/assault, childhood sexual abuse, sexual dysfunction, childhood and adolescent sexuality, role of sexuality in relationships, aging and sexuality, sexual orientation, gender identity, disability, and social and cultural differences.

The topic that received the most emphasis among the 3 program types was “information and skills for contraception.” Disease prevention for sexually-transmitted diseases was also a high-ranking topic.

The authors point out that while it seems understandable that OBG residencies may not include a significant amount of training in male sexual health, there was an absence of evidence on training in child sexual abuse and adolescent female sexuality in the OBG programs. The article notes other omissions of emphasis such as the lack of training among family practice residencies in transgender and gender identity issues, disability and sexuality, and cultural differences.

This article gives some insight into potential topics of training in human sexual health, and the lack of education in physicians regarding topics of sexual function and dysfunction. In addition to lacking knowledge of some topics in childhood, adolescent, and men’s and women’s health, we can be certain that most providers are not instructed in the role of pelvic rehabilitation providers for sexual dysfunction. How can we contribute to a provider’s knowledge of rehabilitation of sexual dysfunction?

Core lectures, including grand rounds and clinical training made up the primary modes of education for sexual health topics. What if each of us reached out to local training programs, or to local teaching hospitals, or even clinical groups and provided an educational platform about our role in sexual health?

In order to provide such training, you might feel as though you need additional resources and knowledge about sexual health and healing. If you would like to explore how we can maximize our contributions to men and women with sexual dysfunction, and explore your own thoughts and beliefs about sexual health, check out Herman and Wallace Pelvic Rehabilitation Institute co-founder Holly Herman’s course on Sexual Medicine for Men and Women taking place next in April in New Jersey.

In our weekly feature section, Pelvic Rehab Report is proud to present this interview with Herman & Wallace instructor Holly Tanner PT, DPT, MA, OCS, WCS, PRPC, LMP, BCB-PMB, CCI

How did you get started in pelvic rehab?

I joined Apple Physical Therapy as an orthopedic outpatient clinic manager back in 2000. The previous manager had begun treating women who had urinary incontinence and we had this (huge) old biofeedback unit. I told the company owners that I would be willing to take a course in treating urinary incontinence, which I quickly did. I also quickly learned that to do a great job in pelvic rehab, and to serve the patients well, you need to keep taking classes to learn about all the other issues that make pelvic rehab so potentially complex and engaging.

What have you found most rewarding in treating this patient population?

The fact that patients are so trusting and share their most intimate issues that may be difficult to discuss. Patients with pelvic dysfunction are so profoundly grateful for the help they receive, and that in turn inspires me to want to be helpful.

What do you find most rewarding about teaching?

I love providing a groundwork upon which the therapists can build through their own practices and through other coursework and knowledge they bring to the table. There is never one approach or one course that can provide an answer for each patient, and as an instructor for Herman & Wallace, I have the privilege of standing on the platform that Holly Herman and Kathe Wallace established when they founded the Institute. I feel that I get to fast-track the therapists by sharing what I have learned through experience and all the training that I have received, and then they can keep expanding the knowledge and skills within our field. I also learn a lot myself through the generosity of the therapists who bring their knowledge and experience to the courses.

If you could get a message to all therapists about pelvic rehab, what would it be?

Shadow a pelvic rehab therapist for half a day. That's all it will take to see the world that opens up in front of you, to feel inspired by the amount of issues that go "missing" and how to address them, and also how to notice how simple and meaningful it is to offer some guidance or hope to a patient who has pelvic dysfunction.

If you could make a significant change to the field of pelvic rehab or the field of PT, what would it be?

Now that more therapists are joining the ranks of pelvic rehab, I hope that we see more of them move into treating men and children. As Dawn Sandalcidi (who teaches about pediatrics for the Institute) shares with us, many of the pelvic dysfunctions start in childhood, and we must get to the kids as soon as possible.

What is your favorite topic about which you teach?

My favorite condition to treat and lecture about is definitely scrotal pain. There is such a paucity of awareness about the potential causes of scrotal or testicular pain, and men have been suffering way too long when they have this issue. In my experience, men can respond very quickly and completely with intervention.

This post was written by Steven Dischiavi, MPT, DPT, ATC, COMT, CSCS, who teaches the course Biomechanical Assessment of the Hip and Pelvis. You can catch Steve teaching this course in May at Duke University in Durham, NC.

One thing that jumps out at me when treating a professional athlete, is that they have “a guy or gal” for everything! Most high profile athletes have a physical therapist, athletic trainer, acupuncturist, nutritionist, massage therapist, personal trainers for speed, power, cross fit, and pretty much “a guy or gal” for anything that has something to do with athletic performance or injury prevention. In most recent years I have been hearing more and more that athletes use someone that can analyze their movement and develop corrective exercises for them. These professionals are not just physical therapists, but some are personal trainers, exercise physiologists, chiropractors, and so on…

This has clearly been leading to a paradigm shift in not only evaluation of the athlete, but more specifically how we treat our athletes and clients. The Functional Movement Assessment is a tool that is gaining more and more popularity. It identifies “movement dysfunction” and then sets out to manage these movement patterns. I am a firm believer in functional movement assessment, and I believe it does need a larger role in our profession…I believe this so strongly I have recently changed gears professionally and have accepted an assistant professor position on the Physical Therapy faculty at High Point University. I want to affect change from within!

That said this is a very slippery slope right now in our profession. There are many people that believe that functional assessment is necessary. These same people cannot agree on the best way to do this and the there is a paucity of evidence to support a specific method at this time. This has driven me to continue to push the envelope in how to assess human movement and what is the cornerstone of this philosophy. I think the cornerstone is the hip and pelvis. I know this is somewhat broad, but after working professional hockey for 10 years I saw first hand what the hip and pelvis brings to the table. This led me to integrate this cornerstone into all facets of my treatments with all types of clients, young, old, big, small, athletic human, non-athletic humans! It was a quantum leap when the evidence caught up to practice and we stopped taping the patella because we were able to wrap our heads around the fact that it’s the track moving under the train! This momentum continues, because I am in a state of the art biomechanics lab everyday watching and learning how we can extrapolate these concepts and continue to move forward and advance movement theory. This has also allowed me to see that there is still a need about how we treat movement dysfunction. Which has led me to continue to work on the concept of the Dynamic Integration of the Myofascial Sling Systems!

If you attend this course I think you will look at human movement a little differently. I think you’ll enjoy the creative ways we can activate particular muscle chains to integrate and coordinate complex movements with more efficiency.

Yes, Herman & Wallace traditionally focuses on the women’s health practitioner. This course gives women’s health practitioners more treatment options to go with their unbelievable manual therapy skill set. This course offers many therapeutic exercise options that can help control the neurologic changes they are creating with their clients. Past course participants from the women’s health arena have continuously commented that they have gained a new tool in their toolbox to address movement imbalances and a way to integrate more function into their exercise programs. The sports and ortho PT will really enjoy this course. It will challenge some of their current paradigms and stir up some lively conversation on functional movement assessment and how to treat movement dysfunction when identified. Sports/ortho PTs consistently report how refreshing it is to consider new things in the profession. These PTs will leave this course challenging some of the traditional approaches they have taken. The reports back to me are usually that the sports/ortho PTs have had fun at this course and look forward to trying what they have learned and performed in lab sessions and applying it with their clients. I look forward to having you in class and having some fun and trying a lot of new exercises and discussing how the assessment of human movement and how identifying movement dysfunction is the direction things are going. William Blake once said “what is now proven, was once only imagined!” I don’t think movement analysis is quite proven yet, but we’re definitely applying science to the art of practice!

Research in the field of sexual dysfunction has taught us several things about patients and healthcare visits. Most medical providers don’t ask about sexual function, most patients don’t bring it up, and women’s sexual health has a history of being undervalued and under-evaluated. Authors Maciel and Lagana describe the common myth that as women age, sexual interest decreases, and review literature to propose improved strategies. The study highlights the fact that there are positive physical health effects for older adults, and that by approaching sexual desire through a biopsychosocial method, further understanding of the issues can be gained.

Several factors have been found to be linked to healthy sex in older females. Having a positive attitude towards sex, an interesting an interested partner, good health, and a willingness to experiment sexually can all contribute to an active sex life. Women who are dealing with high stress, anxiety, and depression are known to be less sexually active. In this paper, the authors describe the work of Sobecki and colleagues, who found that older women have just as much interest in talking about sexual health as younger women, but that doctors aren’t usually asking about it. Sobecki et al. found that a patient reported feeling less embarrassed about bringing up sexual dysfunction if the medical provider demonstrated a professional demeanor, comfort with the topic, and a disposition that is kind and empathetic.

This last point seems worthy of pause and reflection in relation to the role of the pelvic rehabilitation provider. I would submit that most pelvic rehab therapists are highly capable of presenting a professional, kind, and empathetic demeanor. I wonder how many of us, however, had enough education regarding sexual health to demonstrate to patients a level of “comfort with the topic” that inspires a patient to bring up sexual concerns. The more comfortable we are with our own sexuality and the more knowledgeable we are about sexual health practices that are outside of our own experiences, the more we have to offer to our patients.

This excellent review article describes issues that older women often face: menopausal shifts in hormones and vaginal and perineal health, concerns about body image and self-worth. The authors also point out that the healthcare system has medicalized menopause, so that most women are offered little more than pharmaceuticals. One simple suggestion offered in the article is use of the Decreased Sexual Desire Screener that can help identify areas of concern in sexual health. If you are interested in learning more about sexual health and dysfunction, check out Institute founder Holly Herman’s Sexual Medicine for Men and Women continuing education course taking place next in April in New Jersey. If that date does not work for you, you could sign up early for the next course in San Diego in November!

This post was written by H&W instructor Elizabeth Hampton. Elizabeth will be presenting her Finding the Driver course in Milwaukee in April!

One of the most consistent questions that we hear at the Pelvic Floor 2B course is, “How do you choose between a pelvic floor and a musculoskeletal exam during your first visit with a pelvic pain client?” The answer depends on a number of factors, which include your clinical reasoning, toolbox, the client’s presentation, the clinical specialty, and expectations of the referring provider as well as the expectations of the client. It can be stressful to imagine gathering a detailed history, testing, client education and a home program within the first visit! Now that we have less time and total visits to evaluate and treat these complex issues, it can be overwhelming to know where to start.

Chronic pelvic pain has multifactorial etiology, which may include urogynecologic, colorectal, gastrointestinal, sexual, neuropsychiatric, neurological and musculoskeletal disorders. (Biasi et al 2014) Herman and Wallace faculty member, Elizabeth Hampton PT, WCS, BCB-PMD has developed an evidence based systematic screen for pelvic pain that she presents in her course “Finding the Driver in Pelvic Pain”. “There are a number of extraordinary models that exist for treatment of pelvic pain including Diane Lee’s Integrated System of Function, Postural Restoration Institute, Institute of Physical Art and more,” states Hampton. “However, regardless of the treatment style and expertise of the clinician, each clinician should be able to perform fundamental tissue specific screening. If a client has L45 discogenic LBP with segmental hypermobility into extension, femoral acetabular impingement, urinary frequency > 12/day as well as constipation contributed to by puborectalis functional and structural shortness, all clinicians should be able to arrive at the same fundamental findings during their screening exam. The driver of the PFM overactivity(3) needs to be explored further as local treatment alone (biofeedback and downtraining) will not resolve until the condition causing the hypertonus is found and treated.” Finding the Driver in Pelvic Pain is a course that models a comprehensive intrapelvic and extrapelvic screening exam with evidence based validated testing to rule out red flags, understand key factors in the client’s case as well as develop clinical reasoning for prioritizing treatment and plan of care. The screening exam complements any treatment model as it identifies tissue specific pain generators and structural condition, which will lead the clinician to follow their clinical reasoning and treatment model. Once the fundamentals are established, the clinician can move beyond screening and drill down into treatment of key factors which may include specific muscle gripping patterns, arthokinematic assessment and respiratory evaluation and retraining, among others.

Co-morbidities are common in pelvic pain are well documented (1, 2) and clinically these multiple factors are the reason pelvic pain is complex to evaluate and treat. Intrapelvic (urogynecologic, colorectal, sexual) as well as extrapelvic (orthopedic, neurologic, psychological and biomechanical clinical expertise) are required for skilled evaluation and treatment of this population. It is precisely this complexity, which makes working with pelvic pain clients challenging and extraordinarily rewarding. Physical therapists are uniquely skilled to put all of the puzzle pieces together in these complex clients. Finding the Driver is being offered twice in 2015: April 23-25, 2015 at Marquette University and again in the fall. Check Herman Wallace.com for further details.

1. Chronic pelvic pain: comorbidity between chronic musculoskeletal pain and vulvodynia. Reumatismo: 2014 6;66(1):87-91. Epub 2014 Jun 6. G Biasi, V Di Sabatino, A Ghizzani, M Galeazzi
2. http://www.jhasim.net/files/articlefiles/pdf/XASIM_Master_5_6_p306_315.pdf
3. IUGA/ICS Terminology for Female Pelvic Floor Dysfunction. http://c.ymcdn.com/sites/www.iuga.org/resource/resmgr/iuga_documents/iugaics_termdysfunction.pdf

An article appearing this year in Arthroscopy details a systematic review completed to determine if asymptomatic individuals show evidence on imaging of femoroacetabular impingement, or FAI. Cam, pincer, and combined lesions were included in the results. To read some basics about femoroacetabular injury, click here. Over 2100 hips (57% men, 43% women) with a mean age of 25 were studied. (Only seven of the 26 studies reported on labral tears.) The researchers found the following prevalence in this asymptomatic population:

Cam lesion: 37% (55% in athletes versus 23% in general population)

Pincer lesion: 67%

Labral tears: 68%

Mean lateral and anterior center edge angles: 30-31 degrees

The authors conclude that femoroacetabular impingement tissue changes and hip labral injury are common findings in asymptomatic patients, therefore, clinicians must determine the relevance of the findings in relation to patient history and physical examination. Because hip pain is a common comorbidity of pelvic pain, knowing how to screen the hip joint for FAI or labral tears, rehabilitate hips with joint dysfunction, and help someone return to activity following a hip repair is valuable to the pelvic rehabilitation therapist.

As the athletic population may have increased risk of hip injuries due to overuse, traumatic injury, or vigorous activity, being able to address dysfunction in both high level and less active patients is necessary. Herman & Wallace faculty member Steve Dischiavi has developed a course rich in athletic examples and including education about activating fascial systems in various planes. If you are ready to step up your game related to Biomechanical Assessment of the Hip & Pelvis, check out this continuing education course taking place next in Durham, North Carolina in May.